The Paradoxical Sinclair Method For Treating Alcohol Dependence

Mark Dombeck, Ph.D.

Has anyone here ever heard of the Sinclair Method for handling Alcoholism before? I had not ever heard of it before yesterday, and might not have ever heard of it either, but for the podcast musings of Dr. David Van Nuys, the host of ShrinkRapRadio, who recently interviewed Dr. David Sinclair, an American psychologist and alcohol researcher at his home in Finland. Apparently, Dr. Sinclair has worked out of Finland for the last several decades. When you're a researcher you have to do things like move to Finland sometimes; you basically have to go where people are willing to give you money to get your research done.

Anyway, this is not an essay about Finland; it is, rather, an essay about the Sinclair Method, which is a radical rethinking of traditional treatments for alcoholism. Now, my knowledge of Sinclair's method is limited to what I have learned in Dr. Dave's podcast; I have no direct knowledge of whether or not this treatment actually works. Readers and listeners who get interested in this method and want to try it out need to keep the old saying in mind, "Let the Buyer Beware". Keeping this in mind, however, everything I heard Dr. Sinclair say in that podcast makes sense in the context of the other psychology knowledge I have, so I think this is all worth describing.

Sinclair's treatment method can be quickly summarized. Take an alcoholic patient and prescribe him or her some short-acting opioid antagonist medicine (probably in pill form) that he or she can take before drinking. Instruct the alcoholic person to take one of these pills shortly before they have a drink. Apart from the need to take their pill in advance of drinking, they are to keep drinking as they normally would. They are to do this every time they drink for the rest of their lives. If the alcoholic patients are able to comply, Sinclair suggests that their drinking rates will naturally decline over several months to normal or below normal social drinking rates. There will be no need for detoxification, because detoxification will occur naturally and gradually (and thus safely) over a period of months. There will be no need for psychotherapy such as relapse prevention, or alcoholics anonymous, because the craving for drink will actually gradually and naturally fall off with sustained use of the opioid antagonist medications as prescribed.

That is how the method is supposed to work. Before describing why the method is supposed to work, I want to be sure to define some of the technical terms I've used above so that everyone is clear on what they mean.

The terms used to describe the magic medication are first up for definition. I've used three terms here: "short-acting", "opioid" and "antagonist". Let's start with the meaning of opioid. The opioids are a family of medications that are used medically for pain management, and which are also abused as street drugs for the same pain-management purposes. The opioid family includes heroin, methadone and morphine, and also vicodin, percocet, codine and oxycontin. When you take an opioid, it removes your pain feelings.

The reason that opioid drugs have these pain-removing properties is because they are highly similar to chemicals that occur naturally inside the brain which are known as endorphins which serve a similar pain-relieving, pleasure-producing function (amongst other functions). Endorphins function inside the brain as neurotransmitters; chemicals that serve a signaling function, telling neurons to activate (to be come excited and send an action potential electrical signal down its length) or to become inhibited (and fail to produce the action potential electrical signal). Endorphins in the brain have their excitatory or inhibitory effect on neurons by physically interacting with those neurons. The little molecules of endorphines float from the end of one neuron through a space called a synapse over to the start of another neuron, where there are little structures known as receptors that are specialized to catch and hold the endorphin molecules. The shape of the receptors changes (more or less) when the endorphines contact them. A consequence of the shape change is that a little doorway opens, a little pump turns on, and another set of chemicals are exchanged between the interior and the exterior of the neurons. It is this last chemical exchange that makes the neuron either fire or not fire. Imagine that this sort of thing is happening inside your brain right now a billion times each second (for this is is the normal way neurons function all the time) and you start to see how fantastic it all is.

Anyway, moving on, the opioid drugs like heroin and codeine are what are known as agonists for endorphin receptors. This means, they are so similar in shape at the molecular level to the endorphines themselves that the receptors can't tell the difference between them and the endorphines. The presence of either sort of molecule will open the receptor doorways and start the pumps working.

An opioid antagonist is the opposite of an opioid agonist. An antagonist drug is one that has mostly the same shape as the natural endorphines but not quite the right shape. Antagonist drugs fit into receptors just fine, but they don't open the little doorways or start the pumps. Instead, they just clog up the receptors and keep any opioid agonists that may be present in the area from doing their thing.

Now, if an opioid agonist like heroin produces a feeling of pleasure and freedom from pain, an antagonist drug will have the opposite function. It doesn't create pain feelings, per se, but it does take away pleasurable feelings. This is the key factor that Sinclair is depending upon for his method.

The last term here to describe is "short-acting". Drugs can be either long acting or short acting. Short acting drugs have their effect quickly and then that effect goes away. The effect comes on all at once and can be rather intense sometimes, but then fades away rapidly. In contrast, a long acting drug comes on slowly, and has a mild effect that is, well, long-lasting. Sinclair calls for short acting forms of opioid antagonist drugs, because he doesn't want to have the effect of these drugs to last too long. Imagine the consequences of taking a long-acting drug that reduced the pleasure you found in living your life. Suddenly most aspects of your life would lose their luster and you might become depressed (or at least like your life less). A short acting pleasure reducing drug, in contrast, is just the ticket for what Sinclair has in mind, because he is proposing that this pleasure-reducing drug be paired with drinking. The effect needs to be just long enough to suck the pleasure out of the drink, and no longer. The rest of life should not be impacted. Using a short acting drug allows this isolation of the drug's effect to be accomplished.

So, the short-acting opioid antagonist drug is paired with drinking, and the result is that each drink is experienced as less pleasurable than it would be without the drug. This is where Learning Theory kicks in. Learning theory teaches us that people are more likely to continue a behavior that they find pleasurable and thus rewarding, and that they are less likely to continue a behavior that they find aversive or distasteful and thus punishing. Think back to Pavlov's doggies for a moment. The great Russian scientist was able to teach dogs to drool upon hearing a bell ring, by subjecting them to multiple instances where he rang a bell and then presented food. Over time, the bell sound, which initially meant nothing to the dogs, took on the intrinsic meaning that food had for them. In effect, the dogs had learned that the bell sound meant that they were about to be fed.

Animals and people are capable of learning things, for sure. They are also capable of unlearning things. The process of unlearning things is known as extinction. In the classical conditioning paradigm, learning is the result of a pairing between something that is intrinsically rewarding (such as food) and something that has no intrinsic meaning (such as a bell). To unlearn or extinguish something learned in this manner, you detach the intrinsically rewarding thing (the food) from the other thing (the bell). In other words, you ring the bell a hundred times and never provide food thereafter. Over time the dogs (or people) will learn that the bell doesn't mean food is on the way anymore and there is no reason to drool. You can argue about how to talk about this phenomena of extinction I suppose. Maybe you are unlearning the connection between the bell and the food, or maybe you are learning something new (e.g., that there is no relationship between the bell and the food), but the net result is the same.

So, Sinclair is basically extinguishing the relationship between drinking behavior and pleasure. He has the alcoholic take the anti-pleasure pill before drinking, and then when the drink is actually consumed, it just doesn't have that kick it used to have. Over time, the tight compulsion to consume alcohol just sort of fades away as the brain learns that the thrill is gone.

There is a catch here, of course. The brain isn't stupid, and it doesn't like change. When you take a pill to suppress pleasure, the brain doesn't like that and fights back by increasing the total number of opioid receptors in the brain; a process known as up-regulation. The brain's strategy is basically, that it tries to turn up the sensitivity it has to opioid agonists so as to restore normal functioning. This is no problem so long as you stay on the pills, but woe be you if you go off them and drink. If that happens, well, each drink is going to be better than ever before (magnified as its impact will be by the increased numbers of opioid receptors), and problem drinking will set in again in record time. So, to be clear, once you go on the Sinclair treatment, you are foolish to go off it if you plan on continuing to drink in any way shape or fashion.

The Sinclair treatment attacks the behavioral basis for alcohol addiction; it does not work directly on the physiological addiction itself (e.g., that body dependence which requires gradual detox to remove).
Importantly, this treatment is based on learning, and learning can only occur if drinking continues. So paradoxically, it is important, vital even that alcoholics continue to drink while following the Sinclair protocol. If they don't drink and take pills as prescribed, they will not learn that alcohol's thrill has gone flat, and will not stop drinking. The fact that this therapy absolutely requires that drinking continue has got to be terrifying to most treatment providers who are thinking (quite rightly) that excesses of drinking need to be shut down as fast as possible. The idea with the Sinclair method is that the straightest path to the goal of drinking reduction is NOT a straight line, but rather a winding road.

Why have I never heard of the Sinclair method before? If this is so great, why doesn't everyone know about it? The research is not new. Most of it was done in the 1970s and 80s, and apparently, the FDA has studied the method and approved it for use in America over a decade ago (Note: I have not confirmed this – my source for this approval is anecdotal).

Wikipedia (which produces democratic but not always expert or entirely factually correct articles) has this to say:

"Dissemination of information of the treatment has been blocked by all of the existing treatment organizations largely because their existence depends upon the continued use of the treatments that they provide.
The "give 'em a pill and send 'em home" simplicity of the system is anathema to our current alcoholism treatment industry. Most treatment centers rely upon inpatient treatment for funding, and would cease to exist if widespread adoption were to occur. Alcoholics Anonymous opposes the treatment on two fronts - the use of drugs and the continuation of drinking...

The medical community has been largely unconvinced of the effectiveness of this cure because of the extreme shift in mindset necessary to accept a treatment for alcoholism that involves continued consumption. To further cloud the matter, many studies have been done involving using naltrexone to help enforce abstinence - a purpose for which it is poorly suited at best. Although their "failure due to relapse rate" has no bearing on the Sinclair Method, most doctors see a "this drug failed" result and don't look to see how it was used....

Other obstacles are more mysterious and tentative. It is guessed that the pharmaceutical company that makes the antagonist does not wish to pursue advertising this treatment because its use would decrease the sales of other more profitable drugs. Although insurance companies would benefit from the decrease in inpatient alcoholism treatments, it is suggested that they would lose money in the long run from former alcoholics who no longer let their health slide until they lose their jobs and their insurance."

There is probably some truth to some of these assertions. I can easily believe that psychiatrists (who are often ignorant about learning theory, not having receiving systematic instruction in that field) might not really "get" how this treatment has its effects and be weirded out by the paradoxical (and even dangerous) instructions (e.g., to keep drinking) that are necessary to make this therapy work properly. Recall that the core of the treatment is essentially behavioral in nature and not biological, even though medication is used to set up the learning. Even so, you can hopefully smell the odor of bias that is present in this above quoted text. Clearly, the author here has a bone to pick with the establishment. As to whether the bone is a reasonable one, I simply cannot say given my present lack of practical knowledge concerning this treatment.

I want to be clear that I am not recommending the Sinclair Method as a viable means of treatment for alcohol dependency at this time. I simply do not have the information I would need to make such a recommendation. Until I have such information in my brain and am convinced by it sufficiently, I can only recommend conventional treatments for alcohol dependence (e.g., medically supervised detoxification and treatment (inpatient or outpatient), relapse prevention psychotherapy, and support groups such as Alcoholics Anonymous. I talk about the Sinclair Method because it is coherent, and it sounds like it might very well work. I offer this explanation as a means of raising awareness of possible alternatives to conventional treatments that seem to offer promise.

People interested in learning more about the Sinclair Method can visit http://www.sinclairmethod.com which provides some educational information (although not much more than is available here). There is a little quicktime movie on the site for those who want to see Dr. Sinclair speak, and of course, Dr. Dave's recent podcast is also an excellent source. There is a treatment clinic in Sarasota, FL, apparently (accessible from the same URL), for those who want to pursue this line of treatment. Please consider this stuff "experimental" at this point in time, and "let the buyer beware".